Association of state policies modifying Supplemental Nutrition Assistance Program (SNAP) eligibility and cancer stage at diagnosis.

Abstract

214 Background: Food insecurity is associated with access to care and is particularly prevalent among adolescents and young adults (AYA) with cancer. The Supplemental Nutrition Assistance Program (SNAP) was designed to minimize food insecurity for low-income households. Under the broad-based categorial eligibility (BBCE) policy, states were given the ability to relax requirements for qualifying for SNAP through increasing the income limit or eliminating the asset test. While most SNAP policy changes under the BBCE policy occurred from 2009-2011, it is unknown whether these policies affect access to care among AYA with cancer. We sought to determine whether state SNAP eligibility policies were associated with stage at diagnosis among AYA patients. Methods: We utilized the Surveillance, Epidemiology, and End Results database to obtain data from 2006-2019 for newly diagnosed patients with cancer ages 18-39 years from 11 states. All cancer types were included with the exception of liquid tumors and other unstaged cancers. Difference-in-differences analyses were utilized to evaluate changes in the percentage of localized and distant stage diagnoses from pre- to post-policy enactment between states that enacted (1) asset test elimination or (2) increased income limit policies. Linear probability models were adjusted for state and year fixed effects, race, ethnicity, sex, metropolitan residence, marital status, county-level income, cancer type, and Medicaid expansion effects. We also accounted for state-level clustering via clustered standard errors. Event study analyses were utilized to assess the plausibility of the parallel trends assumption. Results: A total of 157,380 AYAs with cancer were identified. In adjusted difference-in-differences analyses, there was a 0.67 percentage point (PP) (95% CI = 0.15 to 1.19, P=.012) increase in localized stage cancer diagnoses and a -0.81 PP (95% CI = -1.41 to -0.21, P=.008) decrease in distant stage cancer diagnoses in states with increased income limits for SNAP eligibility relative to other states. There were no statistically significant changes in the percentage of localized (0.87 PP, 95% CI = -1.27 to 3.00, P=.43) or distant (0.05 PP, 95% CI = -1.44 to 1.55, P=.94) stage cancers with policies eliminating the asset test. Among patients with cervical cancer, where screening is recommended in this age group, there were extremely similar patterns. Conclusions: State policies increasing income eligibility limits for the Supplemental Nutrition Assistance Program were associated with a higher percentage of localized stage and a lower percentage of distant stage cancers among adolescents and young adults. These data add to a growing body of literature suggesting that policies that address social determinants of health may improve access to care.